Since 1975 there has
been a 6-fold increase in the routine use of electronic fetal monitoring
(EFM) on low-risk mothers. The obstetrical profession hoped to eliminate
cerebral palsy and other neurological complications through the expanded
use of EFM, combined with the liberal use cesarean section whenever
fetal monitoring data indicated a possible problem. EFM is the most
frequently used medical procedure in the US – 93% of all childbearing
women are continuously hooked up to this equipment during labor. Many
health insurance carriers reimburse hospitals $400 an hour for
continuous electronic monitoring in labor.

However, the consensus
of the scientific literature has never supported the routine use EFM.
One recent study noted that the ability of continuous EFM to detected
potential cases of cerebral palsy during labor is only 00.2%, not
because the electronics of the equipment are flawed but because the
premise is incorrect. In spite of these faulty assumptions, the
universal use of EFM on low-risk women continues unabated and has
resulted in a sky-rocketing Cesareans section rate that was not
associated with better outcomes. In 2003, 1.2 million Cesarean surgeries
were performed in the US (27.5% cesarean rate) at a cost of $14.6
billion. Our current Cesarean rate is over 31% and climbing. Most
disturbing of all is that the public and the press never seem to
question the unlikely idea that normal childbirth is somehow made safer
and better by turning it into an expensive and risky operation.

Yet the obstetrical
policy of ‘pre-emptive strike’ so liberally used for the last 30 years
has failed to make any difference – not the tiniest bit -- in the
incidence of CP and similar neurological conditions. This verifiable
fact is now gratefully used in court to defend obstetricians
facing litigation.

In July of 2003, a
report by the American College of Obstetrician and Gynecologists (ACOG)
Task Force on Neonatal Encephalopathy & Cerebral Palsy stated:

“Since the advent of fetal heart rate monitoring, there has been no
change in the incidence of cerebral palsy. ... The majority of newborn
brain injury does not occur during labor and delivery. …. most instances
of neonatal encephalopathy and cerebral palsy are attributed to events
that occur prior to the onset of labor.”

This report is
widely regarded as the “most extensive peer-reviewed document on the
subject published to date” and has the endorsement of six major federal
agencies and professional organizations, including the CDC, the March of
Dimes and the obstetrical profession in Australia, New Zealand and
Canada.

The September 15, 2003 edition of Ob.Gyn.News stated that:

“The increasing cesarean delivery rate that occurred in conjunction with
fetal monitoring has not been shown to be associated with any
reduction in the CP [cerebral palsy] rate... ... Only 0.19% of
all those in the study [these diagnosed
with CP] had a non-reassuring fetal heart rate pattern..... If
used for identifying CP risk, a non-reassuring heart rate pattern would
have had a
99.8% false positive rate(N.Engl. J. Med
334[10:613-19, 1996). The idea that infection might play an
important role in [CP] development evolved over the years as it became
apparent that in most cases the condition cannot be linked with the
birth process. ” [emphasis added]

An August 15, 2002 report in Ob.Gyn.News stated that:

“Performing cesarean section for abnormal fetal heart rate pattern in an
effort to prevent cerebral palsy is likely to
cause as least as many bad outcomes as it prevents.
... A physician would have to perform500 C-sections for
multiple late decelerations or reduced beat-to-beat variability toprevent a single case of cerebral palsy.”
[emphasis added]

Unfortunately, the
delayed and downstream complications for mothers and babies associated
with this liberal use of Cesarean surgery makes this policy
counterproductive in the extreme. We must keep in mind that the true
purpose of maternity care is to preserve the health of already
healthy mothers and babies and that mastery in this field means
bringing about a good outcome without introducing any unnecessary
harm.

The
other blue elephant in the room that no one is talking about– according to the
scientific literature, elective Cesarean surgery isn’t a reliable
method to prevent the pelvic floor problems sometimes associated
with childbearing; “purple pushing” during 2nd stage
labor identified as damaging to the soft tissue of the birth canal;
study confirming that traditional upright positions provide the most
room for baby to be born normally

Cesareans not safe or
effective for preventing pelvic problems: Having debunked the
‘prophylactic’ use of Cesarean to prevent cerebral palsy in babies,
elective C-section is now being promoted as a prophylactic procedure to
eliminate pelvic floor problems later in the woman’s life. However,
reputable research also does not support the use of elective Cesarean
surgery as either a safe or a reliable method to achieve this goal.

In an article entitled
“Elective
Cesarean Section: An Acceptable Alternative to Vaginal Delivery?”,
Dr Peter Bernstein, MD, MPH, Associate Professor of Clinical Obstetrics
& Gynecology and Women's Health at the Albert Einstein College of
Medicine, reported on the failure of the obstetrical profession to
practice evidence-based medicine as it applies to this topic.
Addressing the popular notion that pelvic floor damage and incontinence
were the inevitable result of normal birth (to which cesarean surgery
was the proposed remedy), Dr Bernstein observed:

“...these adverse side effects may be more the result of how
current obstetrics manages the second [pushing] stage of labor. Use of
episiotomy and forceps has been demonstrated to be associated with
incontinence in numerous studies. Perhaps also vaginal delivery in the
dorsal lithotomy position [lying flat on the back] with encouragement
from birth attendants to shorten the second stage with the Valsalva
maneuver [prolonged breath-holding], as is commonly practiced in
developed countries, contributes significantly to the problem.”

A guest editorial
published in Ob.Gyn.News; August 1, 2002 by Dr. Elaine Waetjendebunked the idea that elective cesareans can reliably prevent
the need for pelvic surgery later in life. She stated that a:
“[physicians] would have to do
23 C-sections
to prevent one
such surgery.”

Non-physiological pushing
styles and positions are risky for mother and baby both:
Another report in published in Ob.Gyn.News, March 15 2003,
councils against “purple pushing”, which is when the mother holds
her breath and pushes so long that she uses up all her oxygen and gets
purple in the face. Prolonged pushing of this type can cause tiny blood
vessels [capillaries] in the face to break and sometimes blood vessels
in the mother’s eyes will rupture, leaving a tell-tale bright red spot
in the corner, similar to the damage that accompanies a black eye. The
technique that causes this is the Valsalva maneuver, a combination of
prolonged breath-holding and “closed-glottis” pushing.

The author, Lisa
Miller, CNM, JD is a former labor and delivery nurse, a nurse-midwife
and also an attorney. Her report identifies the general idea of
‘directed’ pushing as an undesirable practice that interferes with
normal physiology. Directed pushing usually means the mother is being
coached by the doctor or labor room nurse to hold her breath to a count
of ten and push as long and hard as possible. This is the familiar scene
in which the mother lies in bed on her back, while her husband helps to
hold her legs up in the air and with every uterine contraction, the
hospital staff exhorts her to push “harder, harder, harder, hold it,
hold it, now come on, give it all you’ve got, one more push, come on,
just a little longer, we can see a little bit of the baby’s head, don’t
waste your contraction, etc”, until the mother is out of breath and
purple in the face. This style of “shout it out pushing” is biologically
unnecessary and counterproductive for several reasons.

The hospital’s
coaching policy assumes the mother’s natural biological urge to push is
inadequate or that she wouldn’t know how to push, therefore labor
attendants must instruct the mother to hold her breath to a count of ten
for three times for each pushing contraction. Purple pushing is
uncomfortable, undignified, and, when contrasted with the ‘right use of
gravity’, usually counterproductive. It is not recommended by
evidence-based studies because it disturbs the oxygen-carbon dioxide
balance and causes a dangerous rise in the mother’s blood pressure. Most
regrettably, is an unspoken criticism that somehow the mother isn’t
doing it quite “right” or that she isn’t trying quite hard
enough. Even more disturbing is the anxiety it introduces into the labor
room, which gives everybody in the room the idea that either childbirth
is a race with a big prize for the fastest birth or the baby is
in serious trouble and the staff is tying to get it out before it dies
or they have do a crash C-section. Neither is true for 99.99% of healthy
women.

Purple pushing--or closed-glottis pushing--during which the patient
holds her breath for 10 seconds while pushing is safe in the
approximately 80% of low-risk pregnancies. But that doesn't mean it
works best … in high-risk cases, the baby can't tolerate that
kind of pushing.

....near-infrared spectroscopy used to evaluate fetal effects revealed
that closed glottis and coached pushing efforts led to decreased
mean cerebral 02 saturation and increased mean cerebral blood volume.
All Apgar scores were below 7 at one minute and below nine at five
minutes. [i.e. both
are sub-optimal Apgar scores indicating a transient stress on newborn]

Open-glottis pushing, on the other hand, allows the patient to exhale
while bearing down and leads to minimal increase in maternal blood
pressure and intrathoracic pressure, maintained blood flow, and
decreased fetal hypoxia.”

The study contrasted the conventional supine
position (mother lying flat on her back) to positions in which the
mother was squatting or an all-fours ‘hands and knees’ position. A
report on their presentation, aptly entitled “Upright Positions Offer
Most Room for Delivery”, was published in Ob.Gyn.News [2002;Volume
37 • No 3]. They measured the space available for the baby to pass
through at the three critical landmarks of the childbearing pelvis –intertuberous
diameter, interspinous diameters, and the sagittal outlet. They
discovered that upright positions providedan average of slightly
more than a centimeter at each of these junctions.

“Upright birthing positions provide significantly more room for
delivery in terms of pelvic dimensions, compared with lying supine,
Dr. Thomas Keller said. He and his colleagues …who performed MR
pelvimetry on 35 non-pregnant women to compare pelvic bony dimensions in
the supine, hand-to-knee, and squatting positions.

These differences are statistically significant and confirm the
advantages of birthing positions long practiced in other cultures,
the study's coauthor Dr. Rahel Kubik-Huch noted during an interview.
[emphasis added]

… the theoretical ideal would thus be to adopt the hand-to-knee position
to help the presenting part through the interspinous diameter, and to
squat rather than remain supine as the [head] traverses the sagittal
outlet, said Dr. Kubik-Huch.”

This silly little centimeter of extra space between
lying down and standing up can easily be the difference between a
spontaneous vaginal birth with a healthy baby and a difficult one that
required unusually long and hard pushing, the use of forceps or vacuum
to extract the baby or even a Cesarean section that may leave both
mother and baby in need of prolonged or specialized care after the
birth. It turns out that the ‘right use of gravity’ during the 1st
and 2nd stage of labor is the best way facilitate a normal birth. By
avoiding the use of obstetrical forceps or vacuum, the soft-tissue of
the mother’s pelvis and the unborn baby’s brain are protected from the
damage associated with either prolonged pushing or instrumental
deliveries.

Unrealistic Expectations & Lawsuits ~ a vicious cycle for everyone

The poet Ralph Waldo
Emerson once wrote: “There is no wall like an idea”. That is also an
issue for birth attendants, as people have the idea that high-tech
obstetric care can control or eliminate all possible problems, and like
a thick brick wall, and no amount of information to the contrary is able
to dissuade them. Since 1910, the obstetrical profession has eagerly
promoted the idea that normal birth is a surgical procedure but legally,
this is a double-edged sword. It creates the idea of childbirth as an
event under total control of the physician-surgeon. The resulting
unrealistic expectations make doctors and hospitals much more vulnerable
to litigation when ever there is any problem.First off, it’s not true. As an L& D nurse and midwife, I know
the difference between an operation and normal childbirth. I have seen
hundreds of babies come out before the obstetrician arrived, but have
never once seen anyone’s tonsils or gallbladder take themselves out
before the surgeon arrived.

The combination of
unrealistic expectations and dashed hopes inevitably results in
malpractice litigation. When these statistically predictable
complications occurred despite the obstetrician’s best efforts, the
heartbroken parents believe they have been wronged by their doctor. Most
of the time, this is not the fault of individual obstetricians, but
rather a system predicated on erroneous assumptions that marches forward
in locked step, promising something that no human can do –control the
biology of anther person so as to guarantee zero risk and a hundred
percent perfection. This ultimately fuels a vicious cycle of escalating
interventions, matched by run-away lawsuits, outrageous malpractice
premiums, inflated maternity care costs, dissatisfied customers and
thanks to the elective use of unnecessary Cesarean surgery, preventable
maternal-infant deaths.

19th century childbirth-as-pathology locks the
obstetrical profession out of 21st Century science: Over the last
couple of decades, the medical profession as a whole has broadened
its base by acknowledging and working with the mind-body continuum.
However, the obstetrical profession has never revisited their
historical relationship with birth as a pathological aspect of
female reproduction. As a result obstetrics focuses more and more
tightly on the laboring uterus as a pathological organ, relating to
childbirth as if the uterus were a carburetor that needed to be
tinkered with, the baby was a spark plug that needed to be removed
and the mother’s social and emotional needs were an inconvenient
distraction to the real work of the obstetrician.

Despite a daunting list of
surgical complications, the Cesarean section rate continues on an
unrestrained upward spiral. While the high rate of surgical delivery
(31% for 2006) is usually blamed on the large number of older mothers,
multiple births and fertility treatments, it turns out that the largest
rate of increased in primary Cesarean surgery is for healthy women
giving birth to a single baby at the term.
[Lisa Miller, CNM, JD; Advanced Fetal
Monitoring, Nov 8-9, 2007] The higher the income of the mother,
the greater likelihood that her baby will be delivered by Cesarean
surgery, so obviously it is not medical factors that are fueling the
aggressive use of these obstetrical interventions.

The Cesareans surgery
rate in 2005 was 29%, approximately the same number as students in the
US who graduate from college annually. The last year we have economic
data for is 2003, during which 1.2 million Cesarean surgeries were
performed at a cost of $14.6 billion. As a measure of just how
much money $14.6 billion is, it should be noted the economic damage from
by the Loma Prieta earthquake in the San Francisco area in1989 was
estimated to be only $6 billion and more recently, the US contributed 10
billion dollars to Pakistan since 2001 in an effort to fortify the
Pakistani government’s anti-terrorism efforts.

In spite of
hemorrhaging money on a system that does not improve outcome, public
health officials are predicting a 50% Cesarean rate by the end of the
decade. Some hospitals are actually replacing labor rooms with
additional operating rooms in anticipation of the dramatic rise in
C-sections.

Most inexplicably,
there is a move within the obstetrical profession to promote electively
scheduled Cesarean for healthy women as the preferredstandardof care for the 21st century. Unnecessary Cesarean surgery is the
ultimate iatrogenic intervention in normal birth.One recent study from France identified a 3½ times greater
maternal mortality rate in electively scheduled Cesareans in healthy
women with no history of problems or complications during pregnancy.
Another study on the elective or non-medical use of Cesarean surgery
documented an increased mortality and morbidity for newborns.

Were Cesareans to
become the 21st century standard, it would triple the current
rate to 4 million surgical deliveries every year. This would make
C-sections six times more frequent that the second most common hospital
procedure -- the 700,000 upper GI endoscopies done every year to
diagnose ulcers and stomach cancer. Cesarean as the new obstetrical
standard would put childbirth surgery smack in the middle of our
healthcare system, making American medicine more about elective Cesarean
surgery than treating people who genuinely need medical services. It
would provide yet another opportunity for women and babies to be exposed
to hospital-acquired, drug-resistant infections. Already a quarter of
all hospitalizations are related to pregnancy and childbirth. An
additional 2 1/2 million
Cesareans every year would bump this number up quite a bit, as a result
of re-admissions for various post-operative complications of mothers and
babies.

Pink for girls, Blue for
boys and Green for planet-friendly maternity care

Obstetrics for healthy
women already has an outsized carbon footprint, especially as it relates
to routinely scheduled induction of labor and elective Cesareans
surgery. It is a resource-intensive system that requires more than its
share of the environmental pie. In particular, million more Cesareans
mean more medical schools to train a ballooning numbers of obstetrical
surgeons and anesthesiologists. It means more operating rooms, more
highly-specialized hospital staff, more nurses, more vehicular traffic,
more electricity, more water, longer hospital stays.

Additional surgeries
and prolonged hospitalizations mean an increased number of
drugs-resistant infections to be added to the thousands of
hospital-acquired infection each year and more insoluble antibiotics in
human urine which cannot be filtered out and wind up back in our
drinking water. It also generates huge quantities of bio-hazardous
garbage piling up in land fills. This process of intensive
medicalization feeds back on itself, as hospital-based care becomes both
cause and effect of nosocomial complications. This translates into the
need to build more hospitals, more roads, more traffic and all the other
infrastructures that generate more carbon-laden emissions.

Medicalizing normal birth is also responsible for an outsized economic
burden -- the unproductive cost of unnecessary intervention. This
severely hampers our ability to compete in a global economy against
other countries that, wisely for them, have not saddled themselves with
this albatross. Maternity care policies for healthy women in the vast
majority of other countries, both developed and developing, do not
routinely medicalize healthy women with normal pregnancies. Many EU
countries, Japan and other highly developed countries depend on
time-tested methods of physiological management provided by professional
midwives and general practice physicians. Obstetrical care is used
appropriately whenever there are complications. This small carbon
footprint equates to “green maternity care”.

Doing it
“Smarter”

Worldwide, the economic drain associated the
use of obstetrical interventions on healthy women, particularly the high
Cesarean rates, is causing some countries to rethink their national
maternity care policy. For example, the C-section rate Britain had crept
up to 25% and was still increasing. The UK has historically had a
midwife-based system but in the last 20 years, English midwives have
been used as labor room nurses. As such, they were carrying out the
medicalized procedures of the obstetrical staff, instead of independent
professionals providing physiological management. In February 2007, the
Ministry of Health in the UK announced the reconfiguring of the National
Health Services to reduce the medical costs associated with normal
childbirth. During debate in the British House of Commons on July 11th,
Prime Minister Gordon Brown noted that by 2009, every healthy
childbearing woman in the UK would be able to choose among three
options: [The
Guardian, Feb 6, 2007]

1. Physiological care
by a community midwife in the mother’s home

2. Physiological care
in a local midwife-led unit based in a hospital or community clinic

3. Medicalized care in
a hospital, supervised by a consultant obstetrician, for mothers who may
need specialist care to deliver safely or may want epidural pain
relief

This will bring Britain
back into alignment with their historical maternity care practices,
other EU countries and the entire developing world. The majority of the
world is using the cost-effective model of physiological management as
their standard of care for healthy women, which is approximately 80% of
the childbearing population in most countries.

How Normal Childbirthgot trapped on the
wrong side of history
-- the perfect storm that turned healthy women into the patients of
a surgical specialty and normal childbirth into a surgical procedure
[See stand along file]

Aseptic technique is
the standard of care used around the world by professional birth
attendants who provide physiologically-based maternity care.
This protects mothers and babies from infection through a body of
knowledge and a variety of effective methods, including hand-washings
and universal precautions.
In practical application, it means nothing ever touches the mother that
has come into contact with any source of
contamination –
body fluids of others people or sources of ordinary dirt. All
materials and supplies that could conceivably come in contact with the
mother’s birth canal or the newborn baby are guaranteed to be clean, dry
and free of pathogens. Sterile supplies are used anytime an instrument
or gloved hand must enter into a sterile body cavity or touch tissues
that have been cut or lacerated.

Labor and birth as an
aseptic rather than surgical event
allows continuity of care, permitting laboring women to be cared for by
the same caregiver -- physician or professional midwife-- through out
the process of both labor and birth. It also does not result in
the social isolation of the childbearing mother from her family. Under
aseptic conditions, the spontaneous vaginal birth of the baby is not
considered to be a surgical procedure. No special environment or
equipment is required such as a specially-designed bed with obstetrical
stirrups. The doctor or midwife does not have to be “gowned and masked”
nor does the mother have to lie still on her back or be admonished not
to touch anything. The common sense conditions for aseptic technique
allow the mother to move about and use physiological positions and the
‘right use of gravity’. Aseptic care does not overshadow the mother’s
psychological and social needs. Her family, including other children,
can be present when the baby is being born.

The necessary sterile
supplies for normal birth are simple -- a pair of sterile gloves, a
sterile scissor to cut the cord, a sterile umbilical clamp and a sterile
towel to make a suitable surface upon which to set these instruments.
Accompanying this short list of sterile supplies is the liberal use of
clean linens, paper towels, disposable under pads and diapers, sanitary
napkins and appropriate trash receptacle.

Aseptic practices do
not restrict attendance of normal birth to doctors trained in the
surgical specialty of obstetrics and gynecology. It does not require two
separate professions providing sequential care – a nurse for labor and a
doctor for the birth. It does not disturb the normal process of labor or
birth. It prevents nosocomial infection without requiring a surgeon, a
surgical environment or billing as a surgical procedure under a surgical
code.

The Importance of a
Non-Surgical or "Physiological" Billing
Code

No effort to reform
our national healthcare system can afford to ignore the medicalizing of
normal childbirth. No effort to reform this inappropriately medicalized
system can afford to ignore the issue of the surgical billing code for
normal birth. Presently, there is only one billing code for the entire
spectrum of birth-related care and that is a surgical code. Because
obstetrics is a surgical specialty, normal childbirth has unfortunately
been classified as a surgical procedure for most of the 20th
century. A surgical diagnostic category automatically generates a
surgical billing code, which produces an entirely different (and
expensive) kind of care and a different form of reimbursement.

This surgical designation means the care provided during labor, birth
and immediately after the birth, is divided up into billable units and
parceled out between multiple service providers. This is the most
expensive way possible to pay for maternity care. It eliminates
continuity of care and makes the use of physiologically-based practices
impractical. Under our current system, non-medical forms of care are so
poorly reimbursed that hospitals would quickly find themselves out of
business if they did not purposefully increase the number of billable
procedures done on each maternity patient.

However, a simple solution is at hand and that is a specific billing
code for normal childbirth. To provide continuity of care and to
fairly compensate birth attendants, maternity care for a healthy
population must allow the physician or midwife to use a non-surgical
billing code for physiologically-based childbirth services. A
physiological billing code would permitprimary birth attendants
to be appropriately paid for their full-time presence during active labor as well as the birth and the time and
professional responsibility taken for the immediate postpartum and
newborn period of care.

The Tipping
Point

We can no longer
afford to let the happenstance of 19th century obstetrics get in the way
of the plain facts -- countries that look to physiological care as the
standard for normal births have statistically improved outcomes and a
greatly reduced economic burden. The idea of normal birth as a surgical
procedure has long outlived its usefulness, if, indeed, it ever was an
effective intervention. Restraints imposed by the 21st
century global economy make reform of our maternity care system all the
more urgent. As a national maternity care policy, physiological
principles should be integrated with the best advances in obstetrical
medicine to create a single, evidence-based standard for all healthy
women. Rehabilitation of maternity care practices and reform of
reimbursements categories are both necessary for a balanced,
planet-friendly healthcare system.